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1 Rural Children Increasingly Rely on Medicaid and State Child Health Insurance Programs for Health Insurance By William P. O Hare September 2014

2 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance EXECUTIVE SUMMARY One of the most successful health policy measures enacted in the past few decades was the bipartisan Children s Health Insurance Program (CHIP), passed by Congress in CHIP is currently funded through federal Fiscal Year 2015, but Congress will soon have to decide if it will be funded after that point. This report focuses on differences between rural and urban children in terms of recent trends in health insurance coverage and type of health insurance. Data are examined for states, counties, and congressional districts. Some of the key findings include: The percent of children who lack health insurance is the same in both urban and rural areas (9 percent in 2012) but the source of insurance coverage differs. Children in rural areas are more reliant on health insurance from public sources, including Medicaid and CHIP. In 2012, 47 percent of rural children were covered by public insurance compared to 38 percent of urban children. The share of rural children who rely on Medicaid and CHIP has been climbing rapidly in recent years. The share of rural children covered by Medicaid and CHIP increased from 28 percent in 2000 to 47 percent in The increase in public insurance has been accompanied by a steep decrease in employer-based health insurance for children in rural America. In 2000, 63 percent of rural children were covered by employerbased health insurance, but the figure was only 49 percent in The geographic pattern showing the differences in coverage between rural and urban areas is pervasive. In nearly every state, compared to urban children rural children are more reliant on Medicaid and CHIP. Of the fifty counties with the highest rate of uninsured children, 45 are rural counties. If recent trends continue, the share of rural children covered by Medicaid and CHIP will soon pass the share covered by employer-based insurance. In summary, rural children rely on public health insurance more than urban children and the share of rural children enrolled in Medicaid and CHIP is rising rapidly. 2

3 First Focus September 2014 INTRODUCTION One of the most successful health policy measures enacted in the past few decades was the Children s Health Insurance Program (CHIP) 1 passed by Congress in CHIP is currently funded through Fiscal Year 2015 but Congress will have to decide if it will receive federal funding after that point. 2 Legislation was recently introduced by Senator Jay Rockefeller (D-WV) and Congressman Frank Pallone (D-NJ) that would extend CHIP funding through Given the significance of that Congressional decision, it is important to look closely at CHIP s role in meeting the health needs of children in rural and urban communities. This report focuses on differences between rural and urban children in terms of recent trends in health insurance coverage and the type of health insurance they have. The term rural is used here to refer to persons living outside the officially designated metropolitan areas and the term urban is used to refer to people living inside those metropolitan areas. 4 In this context urban children include those in large cities and their suburbs. Differences for states, counties and congressional districts are also examined through the lens of health insurance coverage for rural children. The primary statistical data used in this analysis come from federal government agencies. 5 Detailed information about the sources of data used in this study is provided in Appendix 1. BACKGROUND CHIP helps states provide health care coverage for children in low-income families 6 whose incomes are above the Medicaid income elegibility threshold. CHIP is implemented at the state level through an expansion of existing Medicaid programs, free-standing CHIP programs, or some combination of these two approaches. 7 Medicaid and CHIP do not provide medical services directly, but help low-income families, secure health services in the private sector. For nearly two decades, CHIP has been vitally important to low-wage workers, allowing low-income parents to obtain health care for their children while continuing to work. Prior to the enactment of CHIP, low-income workers often had to leave their jobs and return to welfare if they wanted to obtain medical care for their children. CHIP is particularly important in places with high rates of seasonal or cyclical employment. When health insurance is obtained through work, people who move in and out of the labor force, or from job to job, do not get continuity of coverage for their family. These kinds of temporary or intermittent jobs are prevalent in rural areas, particularly among workers employed in planting and harvesting crops and/or in seasonal vacation areas. Early investments in preventive health care pay life-long dividends. Studies show that health care early in life has significant positive effects on adults health and risk factors. While having health insurance is only the first step in improving the health of children, health insurance coverage is important. A recent study 8 shows that compared to insured children, children without health insurance are more likely to: 3

4 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance Have no usual source of care Postponed seeking care due to costs Have gone without care due to costs Have not seen a doctor in more than two years Have unmet dental needs due to costs Have not seen a dentist in more than 2 years Health insurance is not only related to medical treatment received as a child, it influences a variety of later life outcomes. One particularly important research project involving Nobel Prize winning economist James Heckman, found a group of poor children between age 1 and 5 who experienced primary pediatric care (both well and illchild care) with periodic checkups and daily screenings had significantly better health outcomes in the thirties than a control group who did not get those health services. 9 Children enrolled in CHIP also had improved physical, social, emotional and school-related health outcomes compared to those who were uninsured. 10 The debate about further funding for CHIP will undoubtedly note that the number of children covered by health insurance provided through an employer (or union or direct purchase) has been falling steadily for many years. Nationwide the number of children covered by employer-based health coverage fell from 48.3 million in 2000 to 41.1 million in In partnership with Medicaid, CHIP was able to provide coverage for children affected by economic recession. As a result, the uninsured rate among children in America is lower today than before the recession. 11 CHIP enjoys strong bi-partisan support with voters, as well as policymakers. A poll conducted on the eve of the 2012 presidential election found that 83 percent of voters (93 percent of Democrats, 78 percent of independents, and 75 percent of Republicans) said extension of CHIP funding was important to them. 12 Another recent poll found that 88 percent of adults (99 percent of Democrats, 87 percent of independents, and 78 percent of Republicans) agree that every child in their state should have health insurance. 13 The most recent data from the U.S. Department of Health and Human Services indicate nearly 8 million children received health insurance coverage through CHIP at some point in Fiscal Year That figure reflects any individual who had been enrolled in CHIP during the year. The number of children enrolled in CHIP in June 2013 was 5.7 million. 15 Because of the way data are collected in surveys and because there is a programmatic overlap between CHIP and Medicaid, survey data generally cannot be shown for CHIP coverage alone. CHIP has been given different names in different states, which means many people may be unsure of whether or not the insurance they have for their children is a CHIP program. Given potential respondent confusion, government surveys typically combine Medicaid and CHIP into a single category usually referred to as public health insurance or government health insurance. The public health insurance category may also include Medicare and Military Insurance, but the vast majority of children covered by public health insurance are enrolled in Medicaid and CHIP. From this perspective CHIP is seen as an important part of a package of health insurance options provided for children in low-income families. 4

5 First Focus September 2014 CHILD HEALTH INSURANCE TRENDS FROM 2000 TO 2012 Table 1 shows that the percent of children (under age 18) lacking health insurance has gone down in both urban and rural areas since The most recent data available indicates that 9 percent of both rural and urban children lacked health insurance in 2012, compared to 10 or 11 percent in Table 1. Health Insurance Coverage for Children (Under age 18) Inside and Outside Metropolitan Areas 2000 to 2012 Percent of Children Without Health Insurance Year Inside Metropolitan Areas (Urban) Outside Metropolitan Areas (Rural) Source: Authors Analysis of Census Bureau s Current Population Survey Micro-data on the IPUMS system. 18 Despite improvements since 2000, however, there were still more than 6.6 million children in the country without health insurance coverage in It should be pointed out that the figures in Table 1 only reflect those children who lacked insurance for the whole year and therefore do not include many children who lacked health care coverage for a portion of the year. Results of the U.S. National Center for Health Statistics Health Interview Survey for 2012 show a big difference between children who were uninsured at the time of the interview (6.6 percent) and those who lacked health insurance at least part of the year (10.4 percent). 20 Moreover, according to one survey even among those who have health insurance, about a quarter (24 percent) say it is inadequate to meet their child s healthcare needs. 21 5

6 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance A recent report from the U.S. Centers for Disease Control and Prevention (2014) also found that 21 percent of children (age 0-17) lived in families that reported having trouble paying medical bills. 22 Not surprisingly, families that are poor or near poor, have much higher rates of problems paying medical bills. Since rural families are more likely to be in this income class, this problem is likely to be more pronounced in rural areas. The point is that the evidence provided from key government surveys should be seen as a conservative estimate of those without health care coverage. Health insurance needs are often larger than the survey data would suggest. SOURCE OF HEALTH INSURANCE For both rural and urban children there has been a big shift since 2000 in how health insurance is provided. In short, fewer children are getting insured through private insurance (largely through their parent s employment) and more are getting insured through public health insurance (largely CHIP programs or Medicaid). Figure 1 shows the type of insurance coverage for rural and urban children from 2000 to The overall trends in the type of health insurance coverage for children were similar in rural and urban areas, but the trends are more advanced or more pronounced in rural areas. Since 2000, the percent of children with employer-based health insurance has steadily decreased and the percent with public health insurance has steadily increased for children in both urban and rural areas. In the two main Census Bureau surveys that collect data on health insurance, the Current Population Survey and the American Community Survey, the term employer-based health insurance is used to reflect health insurance connected with employment. In some other surveys and reports, this is referred to as employer-sponsored health insurance. 6

7 First Focus September 2014 Among rural children the share with Medicaid or CHIP has gone from 28 percent in 2000 to 47 percent in This represents a 75 percent increase in the share of rural children covered by public health insurance. Among urban children there was also an increase, but it was not as large as that seen among rural children. The share of urban children with public health insurance went from 23 percent in 2000 to 38 percent in This represents a 65 percent increase in the share of urban children covered by public health insurance. The increase in public health insurance has been particularly rapid since For rural children, the share with public health insurance went from 37 percent in 2007 to 47 percent in 2012, and among urban children it went from 30 percent in 2007 to 38 percent in This is a big increase over a relatively short period. The economic downturn following 2008 led to more children being eligible for public health insurance because they lived in poor or near-poor families and during this period fewer employers were offering health insurance. The Census Bureau s Current Population Survey shows the percent of rural workers (age 25-64) with employer-sponsored health insurance went from 64 percent in 2008 to 58 in 2013 and the number of rural children in low-income families went from 5.2 million to 5.8 million over the same time period. In rural America the share of children with public health insurance is now nearly the same as the percent with employer-based health insurance - 49 percent with employer-based health insurance compared to 47 percent with public health insurance. This underscores the extent to which children in rural America are heavily reliant on public health insurance for health care. Moreover, the trajectory is clear. Figure 1 shows that on average the percent of children on public health insurance has risen almost 2 percentage points a year since 2007, while the share of employer-based health insurance has fallen about one percentage point a year. If the trajectory seen in the 2007 to 2012 period continues, by 2014 or 2015 the share of rural children with public health insurance will pass those with employer-based health insurance. The rapid increase and high rate of public health insurance for children in rural America underscores how important the Medicaid and CHIP programs are for this portion of the country. 7

8 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance CHILDREN WHO LACK HEALTH INSURANCE In 2012, about 6.5 million children went without health insurance for the entire year. Of these 6.5 million children, about one million lived in rural areas and 5.5 million lived in urban areas. The distribution of characteristics of children lacking health insurance in rural areas are very similar to children lacking health insurance in urban areas (see Table 2). Table 2. Characteristics of Uninsured Children (age 0-17) in Rural and Urban America: 2012 Inside Metro Areas (Urban) Outside Metro Areas (Rural) Total (in 1000s) Number without insurance (in 1000s) Percent of Group Uninsured Total (in 1000s) Number without insurance (in 1000s) Percent of Group Uninsured All children 62,826 5, ,763 1,019 9 Under age 5 16,922 1, , Age 5 to 11 24,260 2, , Age 12 to 17 21,644 2, , In married-couple family 43,154 3, , Other Type of Family 19,672 2, , Non-Hispanic white 24,979 1, , Non-Hispanic Black 4, , Hispanic 9,001 1, , Owns home 28,317 2, , Rents home 17,975 1, , Source: Authors Analysis of Census Bureau s Current Population Survey Micro-data on the IPUMS system. 8

9 First Focus September 2014 CHILDREN IN LOW-INCOME FAMILIES One of the reasons rates of public health insurance coverage are higher in rural America than in urban America is the higher concentration of children in low-income families in rural America. Medicaid and CHIP are intended to reach not only those in poverty but the near-poor as well. Many children living in near-poor families have parents who are employed in jobs that do not offer health insurance, but they make too much money to be eligible for Medicaid. Figure 2 shows poverty data for urban and rural children. In 2012, 52 percent of rural children lived in low-income families (those with income less than 200 percent of the poverty line) compared to 42 percent of urban children. Rural children are also more likely than urban children to be living in deep poverty, defined as family income less than half of the poverty threshold. Figure 2 shows 12 percent of rural children in deep poverty compared to 9 percent of urban children. Since the CHIP program was designed to serve children in low-income families it is important to examine data for children living in low-income families. Low-income families are defined here as those living in families with incomes under 200 percent of the federal poverty line. In 2013, 200 percent of the poverty line for an average family of two adults and two children was $46, Table 3 shows the source of health insurance for rural and urban children by household income expressed as a percent of the poverty level. While the overall percent of children without health insurance is the same for rural and urban children, there are some notable differences by household income levels. Table 3 shows that 90 percent of urban children in poverty have health insurance compared to 86 percent of rural children. At the next income level (2012 household incomes between 100 and 199 percent of poverty) Table 3 shows 87 percent of both groups in this income category have health insurance. For children in families with income at 200 percent of poverty or higher, the percent with health insurance is almost identical. 9

10 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance There are also several notable differences in the source on health insurance for children in low-income families. Rural children in poverty household are more likely than their urban counterparts to get health insurance from a public source (81 percent for rural children compared to 74 percent for urban children). Rural children in poverty households are also a little more likely than their urban counterparts to get health insurance through a parents employer (15 percent for rural children compared to 12 percent for urban children). For children living in households with income just above the poverty line (100 to 199 percent of poverty) rural children are slightly more likely than urban children to get insurance through public programs (55 percent for rural children compared to 52 percent for urban children). Table 3. Urban and Rural Children by Health Insurance Status and Poverty Level Covered by Any Insurance Covered By Public Insurance Covered by Employer- Sponsored Health Insurance Urban Rural Urban Rural Urban Rural Less than 100 percent of poverty to 199 percent of poverty percent of poverty or higher Source: Authors Analysis of Census Bureau s Current Population Survey Micro-data on the IPUMS system. STATE DIFFERENCES The broad national patterns and trends identified in the previous sections mask significant differences among states. While nationally 9 percent of both rural and urban children lacked health insurance, Table 4 shows states ranked by the share of rural children who lack health insurance. The states with the lowest rates of uninsured children in rural areas were Massachusetts (1.7%), Vermont/Illinois (3.5%), and Connecticut (4.0%). At the other end of the spectrum, the states with the highest percent of rural children who are uninsured were Nevada (17.3%), Arizona (17.1%), Alaska (15.4 %) and Texas (14.9%). In other words, the rate of uninsured rural children in Nevada is ten times that seen in Massachusetts. 10

11 First Focus September 2014 There are some clear geographic overtones to this distribution shown in Table 4. The seven states that have the highest percent of uninsured rural children are all in the West (if Texas is included in the West). On the other hand, most of the states with relatively low rates of uninsurance are located in the Northeast and Midwest. These are the similar geographic patterns seen in overall child well-being. 24 The vulnerability reflected in the lack of health insurance is likely to compound the vulnerability reflected by a variety of other problems. Table 4. States Ranked by Percent of Children in Rural Areas Without Insurance: 2012 Rank ( 1 = lowest rate) Percent of Rural Children Without Insurance (Outside Metropolitan) Areas of State 1 Massachusetts Vermont Illinois Connecticut 4 5 Hawaii Iowa Alabama West Virginia New Hampshire New York Michigan Maryland Maine Wisconsin Louisiana Tennessee Pennsylvania Kentucky Ohio Arkansas Minnesota South Dakota Virginia Washington Mississippi Nebraska Kansas North Dakota Oregon North Carolina South Carolina

12 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance 32 Missouri New Mexico Georgia California Wyoming Indiana Idaho Oklahoma Florida Utah Colorado Montana Texas Alaska Arizona Nevada 17.3 DC Delaware New Jersey Rhode Island Source: U.S. Census Bureau Small Area Health Insurance Estimates for 2012 combined with U. S. Department of Agriculture Rural-Urban Continuum Codes NA = Some states do not have any portion of the state outside of metropolitan areas NA NA NA NA The heavy reliance on public health insurance among rural families is geographically pervasive. Table 5 shows that a higher percentage of rural children than urban children rely on public health insurance in every state except four (Connecticut, Nevada, New York, and Wyoming). In 15 states the difference is more the ten percentage points. There were three states (and DC) where such comparisons were not available because there are no counties outside of metropolitan areas. Table 5. Percent of Children (age 0 to 17) with Public Insurance By State and Metro Status: 2012 Inside Metro Areas (Urban) Outside Metro Areas (Rural) Percent of Children with Public Insurance Percent of Children with Public Insurance Rural /Urban Difference (Rural Rate - Urban Rate) Virginia Maryland Kentucky Hawaii Washington

14 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance DC 51.2 NA NA Delaware 34.8 NA NA New Jersey 25.8 NA NA Rhode Island 32.4 NA NA Source: Authors Analysis of U.S. Census Bureau SAHIE 2012 data combined with USDA Rural-Urban Continuum Code While the CHIP and Medicaid programs are federal programs, they obviously differ in their impact across the states. The large differences in terms of eligibility levels, premium amounts, and outreach and enrollment processes among the states highlight the important role states play in making sure vulnerable children get health insurance coverage. COUNTY DIFFERENCES For more than a decade the U.S. Census Bureau has produced estimates of uninsured children for counties through a program known at Small Area Health Insurance Estimates or SAHIE. 25 Examination of data at the county level sheds additional light on rural children who do not have health insurance. Table 6 provides a list of the 50 counties with the highest rates of children without health insurance (all above 18.9 percent). Of the 50 counties with the highest rates of uninsured children, 45 are in rural areas (i.e. outside of a Metropolitan area). The majority of the counties with highest rates of uninsured children are in the Southwest, with 24 counties of the 50 counties located in Texas, 5 in Nevada and 3 in Arizona. Other states with a large number of counties with high rates of uninsured children are Montana with 8 and Alaska with 7. Moreover, a large number of the rural counties with high rates of uninsured children are located in some of the most remote parts of the country. Table Counties with the highest percent of uninsured children by metro status of county: 2012 Rank (1 = highest rate) State County Name Total Population Age 0 to 19 Number Uninsured Percent Uninsured Metro Status 1 TX Briscoe County Rural 2 NV Esmeralda County Rural 3 TX Sherman County Rural 4 AK Yakutat City and Borough Rural 5 TX Throckmorton County Rural 6 MT Garfield County Rural 7 TX Gaines County Rural 8 AK Aleutians East Borough Rural 9 NV Lincoln County Rural 10 TX Jeff Davis County Rural 11 MT Blaine County Rural 12 TX Cottle County Rural 14

16 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance Previous analysis of the Census Bureau s Small Area Health Insurance Estimates also found the vast majority of counties with the highest rates of children lacking health insurance were rural counties. 26 The rural/urban dichotomy used in most of this analysis does not fully capture the extent to which the most rural areas of the country have the highest rates of uninsured children. Table 7 shows a clear relationship between a counties level of rurality (as measured by the U.S. Department of Agriculture) 27 and the percent of children lacking health insurance. The most urban counties have the lowest percent of children without health insurance (around 7.4 percent) in 2012 and the most rural counties have the highest percentage of children lacking health insurance (almost 10 percent). The rate of children lacking health insurance is a third higher in the most rural counties than it is in the most urban counties. Table 7. Number and Percent of Children Without Insurance by Urban/Ruralness of County, 2012 Percent Without Insurance 2000** Percent Without insurance 2012* Percentage point change MOST URBAN MOST RURAL Counties in metro areas of 1 million population or more Counties in metro areas of 250,000 to 1 million population Counties in metro areas of fewer than 250,000 population Urban population of 20,000 or more, adjacent to a metro area Urban population of 20,000 or more, not adjacent to a metro area Urban population of 2,500 to 19,999, adjacent to a metro area Urban population of 2,500 to 19,999, not adjacent to a metro area Completely rural or less than 2,500 urban population, adjacent to a metro area Completely rural or less than 2,500 urban population, not adjacent to a metro area Source: * U.S. Census Bureau, Small Area Health Insurance Estimates 2012 available at ** O Hare, W.P (2007) Rural Children Increasingly Rely on Medicaid and State Child Health Insurance Programs for Medical Care, Policy Brief No. 6, Carsey Institute University of New Hampshire, Chart 1 It is noteworthy that the differences in the percent of children without insurance by the degree of counties rurality are much lower now than they were when a similar analysis was done on data from Table 7 shows the percent of children in different types of counties that lacked health insurance in 2000 and While there is still a rural bias, the expansion of public health insurance since 2000 has substantially reduced the degree of rural/urban differences and benefitted the most rural counties disproportionately.

17 First Focus September 2014 Table 7 shows that the rate of children without health insurance fell by 5.5 percentage points in the most rural counties but only 2.5 percentage points in the most urban counties. In other words, the gap between the most rural counties and the most urban counties was 5.3 percentage points in 2000 but 2.3 percentage points in CONGRESSIONAL DISTRICTS A new source of information on health insurance coverage has become available in the last few years. Questions on health insurance coverage were added to the U.S. Census Bureau s American Community Survey (ACS) in The ACS samples more than 3 million households each year to collect critical data on a variety of topics. Given its large sample size, the ACS provides estimates for the percent of children without health insurance and the percent of children with public health insurance coverage for every congressional district in the country. Table 8 shows the 50 Congressional Districts with the highest percent of uninsured children. All of these Congressional Districts have uninsured rates above 11.7 percent with the highest being the 1st District in Nevada with 19.7 percent of children uninsured. Many of these Congressional Districts are rural in nature. Notably, nearly all of the congressional districts on the U.S.-Mexico border are among the top fifty. Like the county-level data examined earlier, a disproportionately high number of the congressional districts with the highest rates of uninsured children are in Texas - 21 of the 50 Congressional Districts with highest rate of uninsured children are in Texas. Almost all of the top fifty congressional districts are in the South and Southwest regions of the country. 17

20 Rural Children Increasingly Rely on Medicaid & State Child Health Insurance Programs for Health Insurance Table 9 shows the 50 congressional districts with the highest percent of children covered by public health insurance. More than half of the children in all of these districts are covered by public health insurance with the highest rate seen in New York s Congressional District 15 (in New York City) with 77.7 percent of the children covered by public health Insurance. Geographically, these 50 congressional districts are spread out and are seen in every region of the country. Table Congressional Districts with the Highest Percent of Children With Public Health Insurance: 2012 Rank (1 = Highest Percent of Public Sector Congressional District Insurance) Percent of Children With Public Sector Health Insurance Coverage 1 Congressional District 15 New York Congressional District 4 Illinois Congressional District 7 New York Congressional District 13 Michigan Congressional District 34 California Congressional District 40 California Congressional District 13 New York

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